Abstract
Introduction
Degenerative lumbar spondylolisthesis affects approximately 10% of adults over 40. Although decompression has been the treatment of choice, some surgeons note possible instability development after decompression alone (D). Previous studies show that decompression with fusion (DF) has similar complication rates but is better at preventing slip progression and reducing pain. However, others stated the additional instrumentation does not result in superior functional outcomes and has higher costs and complication rates. This study aims to provide an objective, two-arm comparison of the two treatments using systematic review and meta-analysis.
Methods
The study design was a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search was conducted from April 2021 to September 2021 to identify relevant studies using PubMed, Google Scholar, EMBASE, and Cochrane databases based on PRISMA guidelines.
Results
This systematic review included 8 studies (6,669 patients); 7 (6,569 patients) were included in the meta-analysis, with a follow-up period of up to 143 months. The most commonly affected level was L4-5, with females being more affected than males. Visual Analog Scale improvement on back pain was significantly better in DF group (Heterogeneity, I2=32%; WMD −0.72; 95% Confidence Interval (CI), −1.35 to −0.08; P=0.03), as well as postoperative back pain (I2=96%; WMD 0.87; 95% CI, 0.19 to 1.55; P=0.01). The leg pain, Oswestry Disability Index (ODI), satisfaction rate, complication rate, and revision rate were comparable between the two procedures.
Conclusions
Current systematic review and meta-analysis proved that DF is better than D in terms of back pain improvement, and the two procedures are comparable in terms of leg pain, ODI, satisfaction rate, complication rate, and revision rate.
Keywords: Decompression, Fusion, Lumbar Degenerative Spondylolisthesis
Introduction
As one of the most common degenerative conditions in orthopedics, degenerative lumbar spondylolisthesis (DLS) comprises approximately 10% of adults over 40. Surgery is indicated when conservative measures fail; however, there is still a debate regarding the most suitable surgical method for this pathology, particularly between decompression surgery alone (D) and decompression with fusion (DF)1). Even though decompression has been the treatment of choice for a long time, some surgeons argue about the possibility of instability development after decompression alone. Therefore, additional fusion is generally considered in cases of spinal instability, defined by translation of ≥5 mm on flexion-extension radiographs and rotation ≥102,3).
Previous studies indicate that DF is more satisfactory in preventing slip progression and pain reduction than D, with similar complication rates. However, others stated that the additional instrumentation does not significantly affect functional outcomes and has higher costs and complication rates. In patients with many comorbidities, additional fusion may increase the risk of perioperative complications due to increased blood loss and operation time2,4,5).
Until now, few studies compared these two surgical methods for DLS. Through this study, we aim to provide an objective two-arm comparison of the two treatments in the form of a systematic review and meta-analysis. This study will thoroughly discuss as many perioperative factors and outcomes as possible and some cost-analysis. Hopefully, this study will benefit clinicians in choosing the best surgical method for each patient by considering all aspects holistically.
Materials and Methods
The study design was a systematic review and meta-analysis of relevant randomized controlled trials and nonrandomized comparative studies. A systematic search was conducted from April 2021 to September 2021 to identify relevant studies through PubMed, Google Scholar, EMBASE, and the Cochrane database based on PRISMA guidelines (Fig. 1). The keywords used were: “Decompression” AND “Fusion” AND “Degenerative” AND “Spondylolisthesis” AND “Lumbar.”
Figure 1.
Flow Chart Showing Article Selection.
Those data were then manually scanned and reviewed by all authors according to the following inclusion criteria: (1) the studies included a comparative design for decompression alone and DF in DLS, (2) the studies reported a desirable outcome with either continuous or dichotomous variable, (3) studies with follow-up at least 12 months, and (4) the studies in English. Exclusion criteria were patients with rheumatoid arthritis, congenital spine disorders, neoplasm or infection of the spine, traumatic lumbar pathology, and patients receiving other treatment methods. Noncomparative, nonhuman in vivo, and in vitro studies were excluded. Table 1 describes the PICO method for defining the inclusion and exclusion criteria.
Table 1.
PICO Table Describing Inclusion and Exclusion Criteria.
| Study Component | Inclusion | Exclusion |
|---|---|---|
| Population | •Patients with degenerative lumbar spondylolisthesis
•At least 12 months follow-up •One-level and multiple-level surgery |
•Animal studies
•Less than 12 months follow-up •Patients with rheumatoid arthritis, congenital spine disorders, neoplasm or infection of the spine, traumatic lumbar pathology |
| Intervention and Comparison | •Decompression alone
•Decompression with fusion |
•Other methods of treatment
•Studies with only one method of treatment (non-comparative studies) |
| Outcome | •VAS
•COMI •EQ-5D •ODI •JOA score •Operative time •Blood loss •Blood transfusion •Hospital stay •QALY •Cost •Revision rate •Satisfaction rate •Complication rate |
No outcome mentioned or different outcomes |
| Publication | Studies published in English in peer-reviewed journals | •Abstracts, editorials, letters
•Duplicate publications of the same study that do not report on different outcomes •Meeting presentations or proceedings •Non-English studies |
| Study Design | All study design except case reports and review articles | Case reports and review articles |
Abbreviations: VAS, Visual Analog Scale; COMI, Core Outcome Measures Index; EQ-5D, EuroQol 5-dimensions; JOA, Japan Orthopaedic Association; ODI, Oswestry Disability Index; QALY, Quality Adjusted Life Year; PICO, Population-Intervention-Comparison-Outcome
The data extraction was collected under basic characteristics and outcomes. In each study, mean difference (MD) for continuous outcome and odds ratio for dichotomous outcome with a 95% confidence interval (CI) were calculated using Review Manager (RevMan) [Computer program, Version 5.3. Copenhagen: The Nordic Cochrane Center, the Cochrane Collaboration, 2014]. The fixed effect model was used when the heterogeneity was <50%, whereas the random effect model was used when the heterogeneity was >50%.
Results
The systematic review included seven studies (6.456 patients), and six (6.356 patients) were included in the meta-analysis, divided into five outcome analyses. Four studies used Cohort Retrospective design (Level III evidence), while the other three articles used Cohort Prospective design (Level II evidence) (Table 2). A total of 4.759 patients (73.71%) were treated with decompression alone, whereas 1.697 patients (26.29%) were treated with decompression and fusion. Sample age ranged from 57.8-73 years old, and females were more commonly affected than males in both groups (decompression group: 2.563 females, 2.196 males; decompression and Fusion group: 1.211 females and 486 males). The clinical and radiological backgrounds of samples in each study are also described. Clinical background included American Society of Anesthesiologists comorbidity score, smoking habit, Bone Mass Density, and Body Mass Index (BMI). In contrast, radiological background included Meyerding grade, end plate changes, presence of stenosis and scoliosis, when available. L4-5 is the most common level affected, and the follow-up time ranged from 12-91.3 months. Critical appraisal of all studies included was conducted based on Joanna Briggs Institute Scoring System, showing no study had more than three invalid parameters. Table 3 describes sample characteristics, while Table 4, 5 in the supplementary section describe the outcome analysis of included studies.
Table 2.
Studies Included in the Analysis.
| No. | Reference | Journal | Study Design | Level of Evidence |
|---|---|---|---|---|
| 1. | Försth, et al. (2013) | The Bone & Joint Journal | Cohort Prospective | Level II |
| 2. | Alvin, et al. (2014) | Journal of Spinal Disorders and Techniques | Cohort Retrospective | Level III |
| 3. | Austevol, et al. (2016) | European Spine Journal | Cohort Prospective | Level II |
| 4. | Inui, et al. (2016) | SPINE | Cohort Retrospective | Level III |
| 5. | Kim, et al. (2018) | Indian Journal of Orthopaedics | Cohort Prospective | Level II |
| 6. | Yagi, et al. (2018) | Journal of Orthopaedic Science | Cohort Retrospective | Level III |
| 7. | Kimura, et al. (2019) | Clinical Spine Surgery | Cohort Retrospective | Level III |
Table 3.
Sample Characteristics of Included Studies.
| No. | Reference | Patient Characteristics | Follow-up Time (Months) | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Sample Size | Age (years) | Sex | Clinical Background | Radiological Background | Procedure | Levels Treated | ||||||||
| D | DF | D | DF | D | DF | D | DF | D | DF | |||||
| 1. | Försth, et al. (2013) | 5,390 | 70
(50–91) |
67
(50–90) |
F: 2,239 (53%)
M: 2,020 (47%) |
F: 818 (72%)
M: 313 (28%) |
Smoker: 17.2% | Preoperative slip of >3 mm | 4,259 | 1,131 | L2/3: 128 (3%)
L2/4: 298 (7%) L3/4: 554 (13%) L3/5: 1,448 (34%) L4/5: 1,831 (43%) |
L2/3: 23 (2%)
L2/4: 34 (3%) L3/4: 124 (11%) L3/5: 328 (29%) L4/5: 622 (55%) |
25.2
(6.48–66) |
25.2
(10.8–46.8) |
| 2. | Alvin, et al. (2014) | 100 | 57.8±11.9 | 61.4±6.9 | F: 10 (40%)
M: 15 (60%) |
F: 46 (61%)
M: 29 (39%) |
N/A | Grade I Spondylolisthesis (78% mild, 22% moderate) | 25 | 75 | L4/5: 25 (100%) | L4/5: 75 (100%) | 12 | 12 |
| 3. | Austevol, et al. (2016) | 520 | 66.7 (10.0) | 66.3 (9.6) | F: 187 (72%)
M: 73 (28%) |
F: 195 (75%)
M: 65 (25%) |
•Mean ASA: 2±0.57 for D and 2.02±0.5 for DF
•BMI: 26.7±4.6 for D and 26.8±4.6 for DF •Smoker: 19% for D and 20% for DF |
•Foraminal stenosis: 9% in D and 10% in DF
•Degenerative Scoliosis: 6% in each group |
260 | 260 | N/A | N/A | 12 | 12 |
| 4. | Inui, et al. (2016) | 140 | 69.3±8.8 | 63.6±8.4 | F: 35 (58.3%)
M: 25 (42.7%) |
F: 55 (68.8%)
M: 25 (31.2%) |
BMI: 23.7±2.8 for D and 23.6±3.3 for DF | Meyerding:
I: 86.84% II: 12.5% III: 0.6% |
60 | 80 | L2: 3 (5%)
L3: 10 (16%) L4: 44 (71%) L5: 5 (8%) |
L2: 1 (1%)
L3: 18 (20%) L4: 66 (73%) L5: 5 (6%) |
38.0±27.2 | 77.9±37.3 |
| 5. | Kim, et al. (2018) | 129 | 65.5±9.0 | 66.7±8.7 | F: 53 (78%)
M: 15 (22%) |
F: 47 (77%)
M: 14 (23%) |
BMD: −2.2±1.1 for D and −2.0±1.0 for DF | Grade I Spondylolisthesis | 68 | 61 | L4/5: 68 (100%) | L4/5: 61 (100%) | 26.9±7.3 | 27.4±4.3 |
| 6. | Yagi, et al. (2018) | 99 | 68.5±9.3 | 66.7±7.1 | F: 22 (37%)
M: 37 (63%) |
F: 16 (40%)
M: 24 (60%) |
•DM: 11.1%
•Smoker: 16.16% |
•Slippage: 9.3±5.9 for D and 11.3±3.6 for DF
•End plate angular change: 3.9±3.3 for D and 10.9±3.4 for DF |
59 | 40 | N/A | N/A | 36 | 36 |
| 7. | Kimura, et al. (2019) | 78 | 70.0
(34–85) |
68.5
(46–83) |
F: 17 (61%)
M: 11 (39%) |
F: 34 (68%)
M: 16 (32%) |
N/A | Meyerding grade I Spondylolisthesis without intervertebral instability (sagittal translation of >3 mm, segmental motion of >20°, or posterior opening of >5° on flexion/extension radiographs) | 28 | 50 | L3/4: 4 (14%)
L4/5: 23 (82%) L5/S: 1 (4%) |
L3/4: 3 (6%)
L4/5: 47 (94%) |
91.3
(60–143) |
75.0
(60–93) |
Abbreviations: ASA, American Society of Anesthesiologists; BMD, Bone Mass density; BMI, Body Mass Index; D, decompression; DF, Decompression-Fusion; DM, Diabetes Mellitus; F, Female; M, Male; N/A, Not Available
Table 4.
Outcomes Discussed in Included Studies (1).
| No. | Reference | Operative Time (Minutes) | Cost | VAS | ODI | ||||
|---|---|---|---|---|---|---|---|---|---|
| D | DF | D | DF | D | DF | D | DF | ||
| 1. | Försth, et al. (2013) | N/A | N/A | N/A | N/A | •VAS (Leg): 35 (32–37)
•VAS (Back): 35 (32–37) |
•VAS (Leg): 32 (30–35)
•VAS (Back): 32 (30–34) |
27 (26–29) | 27 (26–29) |
| 2. | Alvin, et al. (2014) | N/A | N/A | QALY
Pre op: 0.49 [0.41, 0.58] Post op: 0.74 [0.67, 0.80] ΔQALY: 0.24 [0.16, 0.33] |
QALY
Pre op: 0.46 [0.39, 0.54] Post op: 0.73 [0.64, 0.81] ΔQALY: 0.26 [0.19, 0.32] |
•Pre op: 4.7 (3.8–5.7)
•Post op: 3.6 (2.6–4.6) |
•Pre op: 4.9 (3.7–6.1)
•Post op: 2.3 (1.4–3.2) |
N/A | N/A |
| 3. | Austevol, et al. (2016) | 103 | 170 | N/A | N/A | Leg pain
•12 months: 3.6±2.9 •Improvement: 3.3±3.1 Back pain •12 months: 3.9±2.9 •Improvement: 3.0±2.9 |
Leg pain
•12 months: 3.0±3.0 •Improvement: 3.7±3.2 Back pain •12 months: 3.3±2.6 •Improvement: 3.5±2.8 |
•12 months: 23.3±18.5
•Improvement: 17.5±16.1 |
•12 months: 21.0±18.2
•Improvement: 19.7±18.3 |
| 4. | Inui, et al. (2016) | N/A | N/A | N/A | N/A | Back pain
•Pre: 13±6 •Post: 23±8 Leg pain •Pre: 10±4 •Post: 19±8 |
Back pain
•Pre: 10±6 •Post: 22±8 Leg pain •Pre: 10±5 •Post: 19±9 |
N/A | N/A |
| 5. | Kim, et al. (2018) | 78.35±11.92 | 55.09±12.16 | N/A | N/A | Back pain
•Post: 17.9±11.8 |
Back pain
•Post: 45.1±20.4 |
24.43±10.71 | 36.54±17.0 |
| 6. | Yagi, et al. (2018) | N/A | N/A | Cost:
9,680±6168 QALY: 0.39±0.24 |
Cost:
19,222±332 QALY: 0.48±0.20 |
N/A | N/A | 18.5±9.5 | 14.6±7.8 |
| 7. | Kimura, et al. (2019) | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
Abbreviations: D, decompression; DF, Decompression-Fusion; QALY, Quality Adjusted Life Year; VAS, Visual Analog Scale; ODI, Oswestry Disability Index; N/A, Not Available
Table 5.
Outcomes Discussed in Included Studies (2).
| No. | Reference | Satisfaction Rate | Complication Rate | Complications Encountered | Revision Rate | ||||
|---|---|---|---|---|---|---|---|---|---|
| D | DF | D | DF | D | DF | D | DF | ||
| 1. | Försth, et al. (2013) | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 2. | Alvin, et al. (2014) | N/A | N/A | N/A | N/A | N/A | N/A | N/A | N/A |
| 3. | Austevol, et al. (2016) | 62% | 70% | •Perioperative: 5%
•Patient-reported: 15% |
•Perioperative: 8%
•Patient-reported: 13% |
N/A | N/A | N/A | N/A |
| 4. | Inui, et al. (2016) | N/A | N/A | N/A | N/A | •Dural tear=1
•Transient motor weakness=1 •Deep infection=1 •Symptomatic postoperative hematoma=1 |
•Dural tear=1
•Transient motor weakness=2 •Permanent motor weakness=1 •Deep infection=1 |
N/A | N/A |
| 5. | Kim, et al. (2018) | N/A | N/A | N/A | N/A | •Unintentional durotomy=1
•Superficial infection=2 |
•Superficial infection=2
•Nonunion until 1 year=1 |
N/A | N/A |
| 6. | Yagi, et al. (2018) | N/A | N/A | N/A | N/A | N/A | N/A | 12% | 7% |
| 7. | Kimura, et al. (2019) | N/A | N/A | 4% | 10.7% | •Dural tear=1
•Pulmonary embolism=1 |
•Dural tear=1
•Superficial SSI=2 |
8% | 7.1% |
Abbreviations: D, decompression; DF, Decompression-Fusion; N/A, Not Available
For the postoperative Visual Analog Scale (VAS) on back pain, four studies were eligible to be included in the analysis of this outcome. From a total of 2,014 patients, a calculation on 999 patients undergoing decompression showed a mean back pain VAS of 3.55. Meanwhile, on 1,015 patients undergoing decompression and fusion procedure, the mean VAS was 2.62. Analysis showed a significantly higher back pain VAS in decompression only group (I2=96%; WMD 0.87; 95% CI, 0.19 to 1.55; P=0.01), meaning decompression and fusion was more favorable in terms of postoperative back pain VAS (Fig. 2).
Figure 2.
Forest Plot for VAS Improvement (Back).
Meanwhile, three studies reported leg pain VAS as their outcome. A total of 1,873 patients were included in the analysis. The mean leg pain VAS in the decompression group was 3 (n=927) and 2.7 in the decompression-Fusion group (n=946). Forest plot shows no significant difference in leg pain VAS between the two groups (I2=63%; WMD 0.25; 95% CI, 0.00 to 0.49; P=0.05) (Fig. 3).
Figure 3.
Forest Plot for the Postoperative VAS (Leg).
Out of eight studies included in this meta-analysis, we analyzed the postoperative Oswestry Disability Index (ODI) based on data from four studies involving 1,976 patients. Mean ODI in patients undergoing decompression was 26.33 (n=1,000) and 21.76 in patients undergoing decompression and fusion (n=976). We observed no significant difference in terms of ODI between the two groups following analysis (I2=90%; WMD 4.12; 95% CI, −0.22 to 8.47; P=0.06) (Fig. 4).
Figure 4.
Forest Plot for the Postoperative Oswestry Disability Index (ODI).
Subsequently, we included two studies involving 598 patients to generate results on complication rates. Out of 288 patients in the decompression group, complications occurred in 54 patients (18.75%). Meanwhile, in the decompression-Fusion group, complications occurred in 58 out of 310 patients (18.7%). These results, however, was found to be not significantly different between the two groups (I2=0%; WMD 0.94; 95% CI, 0.62 to 1.43; P=0.78) (Fig. 5). Some complications encountered are dural tears, bleeding, hematoma, wound infection, and transient motor weakness. Pulmonary embolism has also been described in one of the studies.
Figure 5.
Forest Plot for the Complication Rate.
Lastly, we analyzed the revision rate according to results reported by two studies involving 177 patients. Revision surgery was necessary for 9 out of 87 patients (10.34%) in the decompression group and 7 out of 90 patients (7.78%) in the decompression-Fusion group. Nevertheless, this difference was not significant (I2=0%; WMD 1.30; 95% CI, 0.44 to 3.84; P=0.63) (Fig. 6).
Figure 6.
Forest Plot for the Revision Rate.
There were several outcome measures from involved studies in which meta-analysis could not be performed, namely operative time, blood loss, and hospital stay. Operative time was only reported in two studies, with it being significantly longer in the decompression and fusion groups according to both studies. Meanwhile, blood loss was reported in only one study, in which a greater amount of blood loss occurred in the decompression and fusion group (420.02±36.11 ml vs. 180.05±21.10 ml). According to two studies, hospital stays were longer in the decompression and fusion groups, resulting in longer operative times and hospital stays, greater amounts of blood loss, and significantly higher costs.
Discussion
The characteristics of patients from included studies show that DLS occurs more often in older females, affecting L4-5 the most. The higher frequency in older females was associated with menopausal status. Decreased levels of estrogen hormones in postmenopausal females are associated with accelerated disc degeneration and disc space narrowing, a higher prevalence of osteoarthritis, and general laxity of the paraspinal ligaments6,7). A previous systematic review showed a similar result that degenerative spondylolisthesis's prevalence is gender-specific and age-specific. Both female and male patients begin to develop degenerative spondylolisthesis after 50 years of age, with a faster development rate in females than males7). However, a study by Wang et al. (2017) stated that the incidence of degenerative spondylolisthesis does not differ much after the age of 65 years old7). Another study by Wu et al. (2008) also proved that advancing age alone had no significant effect on mortality rate postoperatively8). Some literature also showed L4-5 as the most commonly affected level in degenerative spondylolisthesis, with 6-9 times more likely than other spinal levels to be affected. The iliolumbar ligaments, which firmly hold L5 in their anatomical place, are the fundamental cause for this precise location9). Moreover, the degree of instability and the existence of Modic change was not completely described in most studies included, which might cause bias in the overall analysis. However, the relationship between radiological severity and surgical outcome is not yet established in the existing literature. A study by Weiner et al. (2007) stated that patients with a >50% reduction in spinal canal cross-sectional area, as measured by Magnetic Resonance Imaging, tend to have better outcomes than those with less severe stenosis10). On the other hand, another study by Ulrich et al. (2020) stated that endplate Modic changes have no significant influence on clinical outcomes up to 36-month follow-up, independent of chosen surgical treatment11).
There are many methods of treatment for treating DLS. For decompression alone, two studies used laminectomy4,12). One used laminotomy and one used a microendoscopic muscle-preserving interlaminar decompression technique5). TLIF or PLIF were used in six studies for decompression and fusion1,4,5,12-14). Other studies did not describe the technique used for decompression or decompression and fusion. While the surgical technique varies among surgeons, the outcomes are also different in some aspects, comparing decompression alone with fusion in particular.
In terms of surgery duration and hospital length of stay (LoS), both Kim et al. and Austevol et al. found that decompression and fusion resulted in significantly longer duration and LoS compared to the decompression alone group due to its higher complexity and invasiveness4,12). Kim et al. also found that decompression and fusion significantly resulted in more blood loss and total blood transfusion. Spinal fusion is one of the most common surgical procedures related to blood transfusion, as it often results in significant blood loss. A retrospective study result identified that there were four independent risk factors for significant blood loss in lumbar fusion, including BMI, long segment spinal fusion, excessive spinal canal narrowing, and TLIF. Significant blood loss during lumbar fusion procedure was also related to a higher rate of postoperative complications and a longer hospital LoS15).
Hospital LoS is closely related to Cost-utility analysis. Cost-utility analysis (CUA) is an economic analysis that evaluates the relative costs and health outcomes of alternative management options in quality-adjusted life-years (QALYs), allowing a decision on which option is the most cost effective. One year of perfect health is equivalent to one QALY. The incremental cost-effectiveness ratiois commonly expressed as the incremental cost for a net gain of QALY in CUA, demonstrating the value for money in terms of a specific type of health outcome1,16). Yagi et al. compared the cost/QALY of decompression alone versus decompression and fusion in terms of cost-utility. The cost/QALY in the decompression and fusion group was significantly higher one year after surgery; however, despite the difference in surgical indication, there was no difference in cumulative cost/QALY at three years1). This result aligned with a study by Alvin et al., stating that decompression alone is cost effective for patients with DLS.
In contrast, decompression and fusion are not cost effective at 1-year postoperatively14). Despite the above findings, treatment selection bias still occurs due to diverse healthcare systems in different nations. Presumably, a country with a good national health insurance system has no bias in treatment selection based on patient economic status and insurance type. However, because healthcare systems vary widely worldwide, caution is advised when implementing these findings in other countries.
Regarding postoperative outcomes, pain is one of the most important parameters to assess. Leg pain results from spinal stenosis, while low back pain reflects the mechanical cause of this pathology. Regarding the treatment outcome, Pearson et al. (2011) stated that patients with predominantly leg pain improved better through surgery compared to predominantly back pain patients17-19). In terms of back pain as measured by the VAS, DF is superior to decompression alone. On the other hand, the leg pain did not differ significantly between the two procedures. However, this difference is unlikely to be clinically relevant as the minimal clinically important difference for VAS after spine surgery was said to be 14 points3,20). Kleinstueck et al. (2011) suggested that decompression alone as a less invasive treatment should be favored in patients with predominantly stenotic or radiating leg pain symptoms. However, the exact definition of differentiating “leg pain” and “back pain” is still blurry and has been a topic of debate in the literature, along with its possible clinical implications19). ODI is a valid measure to assess clinical, functional outcomes in patients with spinal disorders (including degenerative spondylolisthesis), comprising several direct, simple questions assessing pain and the patient's ability to perform daily activities. ODI correlated with pain measurements (VAS and Numeric Rating Scale) and was proven consistent with pain improvements21,22). On the other hand, satisfaction rates might be related to each patient's ability to pain-free daily living. Therefore, not significantly different VAS and ODI seem to correlate with not significantly different satisfaction rates between the DF and D groups (though DF has a slightly better satisfaction rate).
As a more invasive procedure, DF was believed to result in a higher complication rate than D; however, our study proved no significant difference in postoperative complication rate between the two procedures. This might be caused by the increasing familiarity of surgeons with DF, resulting in fewer operative times and reducing the complication rate in this group5). Some complications are bleeding, dural tear, wound infection, transient motor weakness, nonunion, and pulmonary embolism. Infection risk increases with longer operative time, and nonunion can only be observed in patients undergoing fusion12). On the other hand, bleeding and dural tear is intraoperative complications that can be reduced with increasing learning curve and experience. In addition, motor weakness and pulmonary embolism might be related to each patient's age, general condition, and comorbidities, needing holistic preoperative planning to minimize these possible complications19).
Though revision rates did not significantly differ between the two procedures, one of the most common causes of revision surgeries is an adjacent segmental disease and pseudoarthrosis in the middle to long-term follow-up1). A study by Kato et al. (2017) also identified scoliosis and lateral listhesis as significant risk factors for revision surgery, where initially, patients with rotatory scoliosis and lateral listhesis of ≥6 mm should be considered candidates for decompression and fusion instead of decompression alone to prevent further instability23). These factors should be considered individually when choosing the most appropriate treatment for the patient.
Finally, this study has several limitations: (1) The studies included are of Level II, and III evidence; (2) The heterogeneity of some analyses is high; (3) Due to the scarcity of studies, single and multilevel pathologies were all included into the analysis. Moreover, some differences in the clinical and radiological background in each study may also cause bias in the overall analysis. However, to our knowledge, this study is the first to formulate a systematic review and meta-analysis on this matter. It is hoped that this study might be beneficial as a guideline in choosing an appropriate method of treatment for patients with DLS while further inspiring other researchers to conduct well-designed trials with a bigger number of samples and perform subgroup analyses.
Conflicts of Interest: The authors declare that there are no relevant conflicts of interest.
Sources of Funding: None.
Author Contributions:
• Ida Bagus Gede Arimbawa: Led the research, gave the idea of this study, supervised the literature selection process, and discussed with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• Cokorda Gde Rama Adi Pranata: Performed literature selection to be involved in the study, performed systematic and meta-analysis, and discussed with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• Sonia Daniati: Performed literature selection to be involved in the study, performed systematic and meta-analysis, and discussed with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• Made Winatra Satya Putra: Performed literature selection to be involved in the study, performed systematic and meta-analysis, and discussed with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• Sherly Desnita Savio: Performed literature selection to be involved in the study, performed systematic and meta-analysis, and discussed with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• I Gusti Lanang Ngurah Agung Artha Wiguna: Literature selection supervision, performed discussion with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• Ketut Gede Mulyadi Ridia: Literature selection supervision, performed discussion with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
• I Ketut Suyasa: Literature selection supervision, performed discussion with the other authors to formulate the discussion and conclusion. Have read and approved the final manuscript.
Ethical Approval: Not applicable as this study is a systematic review and meta-analysis.
Informed Consent: Consent was not required because this study involved no human subject.
References
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